AN INVESTIGATION has found “reasonable grounds for concern” in relation to physical or sexual abuse for 21 past or current residents at a HSE-run nursing home.
In 2020, a healthcare worker at the nursing home was jailed for 11 years for raping a resident known by the pseudonym of “Emily”.
Following the incident, two investigations were undertaken respectively by the National Independent Review Panel (NIRP) and the relevant local Community Health Office (CHO) safeguarding team.
The NIRP reviewed the circumstances surrounding the incident, including the response and follow-up action of staff at the unit at that time. It also looked at the governance arrangements in the unit.
The safeguarding review was undertaken to identify if any further reportable incidents may have taken place.
The HSE has today published the outcome of the two separate investigations.
Between October 2020 and November 2021, the safeguarding review team met with residents, families and staff.
They also carried out a review of safeguarding and incident reports and resident files.
The team sought to ascertain whether there were other reportable incidents under the HSE Safeguarding Vulnerable Person’s at Risk of Abuse Policy which might need to be reported to the Gardai and investigated accordingly.
The team adopted a “zero tolerance approach” to the possibility of abuse occurring. The report outlined that if they had reasonable grounds for concern in relation to sexual or physical abuse, then these were notified to the gardaí for appropriate follow‐up.
The team found “reasonable grounds for concern” in relation to physical or sexual abuse for 21 residents.
The safeguarding team did not investigate any of these allegations and reportable incidents and “this is outside their remit”. They did, however, make the appropriate reports and ensure safeguarding plans were in place. All of these concerns were notified to gardaí.
Reasonable grounds for concern were also found in relation to the psychological abuse of two residents.
The report said concerns relating to psychological abuse do not meet the criteria for notification to gardaí. It said these concerns were managed in line with the Safeguarding Policy 2014 which “outlines the necessary steps that should be taken in relation to safeguarding plans”.
Reasonable grounds for concern were found in relation to one other former resident based on missing sections in this resident’s file.
The full resident’s file has subsequently been located. The safeguarding review team reviewed this file in May 2023 and no concerns were identified.
The safeguarding review team has made five recommendations.
It has recommended the CHO should ensure the implementation of all HSE record management and documentation policies and that this should include regular review and auditing of documentation recording in CHO community nursing unit.
“Fundamental improvement is required to the day to day recording systems to achieve safe healthcare delivery and protect the wellbeing of residents in this Community Nursing Unit. Furthermore, there needs to be clear documentation in relation to safeguarding issues and the decisions made in relation to them,” the review said.
“The voices of the residents, and their will and preference should be clearly documented.”
The team has recommended the CHO should request that the HSE National Safeguarding Office review their safeguarding training in relation to its subject content.
“The learning from this review suggests that abuse of older persons should be given greater priority with a specific focus on the recognition and reporting ofsexual abuse in older adults,” the review said.
The team also recommended that the CHO should ensure that all of its community nursing units have clear supervision structures in place in line with current policies and that this process should be extended to all staff working in residential centres.
The team recommended that the CHO should communicate with national community operations to advise that the learning from this review suggests the development of adult safeguarding legislation and national policy should be progressed.
It said that in the interim, the HSE, An Garda Síochána, Hiqa and Tusla should “develop and actively promote interagency collaboration to ensure appropriate and timely sharing of information to protect adults at risk of abuse”.
Lastly, the team has recommended the development of a welcome/induction pack for residents and relatives.
“This should, along with general information about the running of the home include, clear information about safeguarding protocols. This would indicate how to make a complaint and how to raise safeguarding concerns through the local service, local management, national structures and also the external bodies,” the review said.
HSE chief Bernard Gloster has restated “sincere apologies” to ‘Emily’s’ family.
“In the place she should have felt most safe she came to the greatest harm,” Gloster said.
“Our apology will not take away the trauma and distress both she and they have endured. I am very grateful to them for meeting me recently and allowing me the opportunity to apologise in person on behalf of the HSE. Of equal importance was the value of hearing their experience of the aftermath of this dreadful crime,” he said.
“I have previously said we failed Emily. It is important to recognise that we also failed them. We clearly have a lot to learn and change.”
Gloster said he also wishes to apologise to “the other families whose loved ones were resident in this unit and whose files were examined”.
“I want to assure these families, and indeed all families, that the HSE is fully committed to safeguarding all people in our care and it is clear we have much to do in fulfilling this undertaking,” he said.
Gloster said that 21 files in addition to ‘Emily’ met the safeguarding threshold for referral to gardaí.
“While investigations could not be concluded I am satisfied this is a clear indicator that the approach to safeguarding in this facility was in many ways of a poor standard despite the fact that many very good staff work there,” he said.
The HSE has appointed an external safeguarding expert, Jackie McIlroy, to review both of the reports, conduct her own enquiries and advise Gloster if a further examination of individual records is required to identify past harm.
“If she determines that a further examination is required, I have asked her to outline what period of time this should cover. Ms McIlroy has begun this work and will report to me in the next number of weeks. I have committed to publishing her work,” Gloster said.
McIlroy will also undertake a “high-level review” of the HSE safeguarding policy and procedures and structures.
“This work will recognise that the HSE has roles in safeguarding in both the community and alternative care settings for adults. I have asked for this review to be completed within 16 weeks. Again I will be publishing her work and our response,” Gloster said.
“Finally I want to again apologise to all people affected by these events, conscious that there are many people in care facilities,” he said.
“We recognise the concern they and their families may have on hearing of this case. We will continue to support them in the coming weeks and months as we all work together to ensure we do all we can to provide support to those who need it and to radically overhaul our safeguarding approach – not just in our structures but also our culture.”
Dublin Rape Crisis Centre’s freephone 24-hour National Helpline is at 1800 778888 and is available to everyone.
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